University of Gondar

College of Medicine and Health Sciences

School of Biomedical Laboratory Sciences
Department of Medical Parasitology

MODULE TITLE: HAEMATOLOGY MODULE

MODULE CODE: HEMA-2032
TOPICS: HOOKWORM

Aberham Abere (BSc,. MSc)

21.11.2022 1
 4.1. General features of Nemathelminths

• Round in cross-section

• Unsegmented

• Digestive system complete

Possess mouth, oesophagus and anus

•21.11.2022
Have separate sexes 2
 Hookworms

 Are hematophagous nematodes

 Two major species

Ancylomstoma duodenale
Necator americanus

 Less important : A. ceylanicum, A.

braziliense ,A. caninum , A.tubaeforme, A.
buckleyi
21.11.2022 3
 Epidemiology
• widely distributed throughout the tropics and
subtropics
• >1 billion people are infected world-wide
• Worm burdens do not decline in adult years
• ~600 million cases worldwide (rural poverty >>> urban
slums)
44 million pregnant women infected
• A single adult can lay 5-20,000eggs/day
– cause daily blood loss of 7 million liters
– Most commonly infected are children, agricultural
workers and miners

21.11.2022 4
 Epidemiology…
 Ancylostoma is found in Europe around the
Mediterranean, on the West coast of South America
and in parts of China and India
• Necator is found over much of the western
hemisphere, Africa , central and south America and
South East Asia

21.11.2022 5
 Epidemiology….
 In Ethiopia : Necator americanus is more common than
Ancylostoma duodenale
 highest infection rates: Ilubabor, Kefa, Welega
 A.duodonale is associated with areas of poor soil coverage and
high rate of drainage
 N.americanus is found in red soil areas on flat plain
 Altitude and moisture are the major factors affecting their
distribution
 Hook worm infection is absent in low ,hot dry areas of Ethiopia
and above 2500m altitude
21.11.2022 6
 Habitat

 Adult: Jejunum and less often in the

duodenum of human
 Eggs: In the faeces; not infective to human
 Rhabditiform & filariform larvae: free in soil
and water.

21.11.2022 7
 • Head is slightly
bend (hook) and
• the mouth carries
characteristic teeth
(Ancylostoma) or
plates (Necator)
• The posterior end
of the male worm is
elaborated into a
copulatory bursa

21.11.2022 8
• Teeth in their buccal cavity enable their
attachment to intestinal mucosa; from where
they suck their host's blood

• The worm's mean life span Is 1 - 3 years,

~ 1 year (A. duodenale)
~ 3 - 5 years (N. americanus)

21.11.2022 9
 Morphology….
Egg:
 2x egg are produced by A. duodenale,
(20,000egg/day) than N. americanus
Size : 65-40m
Shape: oval
Shell: very thin & appears as black line
Color: the cells inside are pale gray
Content: contains an ovum which appears
segmented usually 4-8 blastomeres
21.11.2022 10
 Morphology of larvae
Rhabiditiform Larvae Filariform Larvae
1.Size 250-500m 600- 700 m

2.Bucal cavity long short

3.Oesophages 1/3 body length 1/4 body length

4.Tail end Pointed end Sharply

pointed

21.11.2022 11
21.11.2022 12
Hookworm rhabditiform larva Hookworm filariform larva

21.11.2022 13
 Transmission and life cycle
Transmission
 Penetration of the skin by filariform larvae
 Ingestion of the filariform larvae present in the
soil-rare

21.11.2022 14
 Life cycle
• Eggs are passed in the stool, under favorable
conditions (moisture, warmth, shade).
• Rhabditiform larvae hatch in 1 to 2 days in the feces
and/or soil.
• After 5 to 10 days (and two molts) they become
filariform (third-stage) larvae that are infective.
• larvae can survive 3 to 4 weeks in favorable

21.11.2022
environmental conditions.  15
 Life cycle….
• On contact with the human host, the larvae penetrate the
skin & are carried through the veins to the heart, then to
the lungs
• They penetrate into the pulmonary alveoli, ascend the
bronchial tree to the pharynx, and swallowed
• The larvae reach the small intestine, where they reside &
mature into adults 
– They attach to the intestinal wall with resultant blood
loss by the host
21.11.2022 16
21.11.2022 17
 Life cycle

21.11.2022 18
 Pathogenesis

• Causes disease by their attachment to the

human intestine and consequent blood loss and
protein lossing enteropathy
• Secret a complex series of proteins, the
excretory-secretory antigens
• Produce a family of peptides(anticoagulant
proteins) that block the activity of factor vii and
xa.
Inhibit coagulation by a unique mechanism

21.11.2022 19
 Pathogene…
• The blood loss results in anemia,
• severity of which is highly dependent on daily iron
intake and iron reserves of the host
• Iron loss also has an effect on enzyme systems
with an iron prosthetic group, esp
neurotransmitters, and this may be a mechanism
whereby hookworms contribute to the intellectual
deficits associated with intestinal nematodes.
21.11.2022 20
 Clinical features
• Arise from a combination of intestinal inflammation
& progressive iron/protein-deficiency anemia.
• Most individuals with hookworm infection are
asymptomatic (90%).
• High loads of the parasite(20 - 100 worms) coupled
with poor nutrition (inadequate intake of protein &
iron) eventually lead to anemia
21.11.2022 21
 Clinical ….
• Skin penetration and associated secondary bacterial infection
can result in “ground itch”
• Pulmonary phase is usually asymptomatic

• Intestinal phase: adult worms attach to the mucosa and feed on

blood.
• Non specific symptoms, such as abdominal pain, nausea and
anorexia, are associated with the appearance of hookworms in
the gut
• Worms continuously move to new places exacerbating bleeding
21.11.2022 22
 Clinical….
• Blood loss, 0.03 ml (N.americanus.) to 0.26 ml
(A.duodnale) per worm, up to 200 ml per day in
heavy infections
• Chronic heavy infections result in anemia & iron
deficiency
• Malnutrition, stunt growth & poor mental dev`t in
children.
• 21.11.2022
Anemia leads to weakness & fatigue in adults 23
 Clinical features
• The principal mechanism of disease formation is
the development of anaemia, due to the
hookworms taking up blood meals
• This feeding is associated with a blood loss in the
order of 0.05-0.04ml per adult worm.

21.11.2022 24
 Clinical…
• The impact of anemia is clearly dependent on the
nutrition of the host and therefore must take
account of dietary factors, host iron reserves and
the presence of other conditions, such as
menorrhagia.
• Like other intestinal nematode infection,
hookworm infection is associated with
intellectual impairment, and
• Improvement in cognitive function has been
associated with effective treatment with
albendazole.
21.11.2022 25
 Symptoms of hookworm infection depending on the site at which the worm is
present and the burden of worms
Clinical features of hookworm disease

Site Symptoms Pathogenesis

Cutaneous invasion
Local erythema, macules,
Dermal and subcutaneous
papules (ground itch)
migration of larva
Migration of larvae
Pulmona Bronchitis, pneumonitis and,
through lung, bronchi,
ry sometimes, eosinophilia
and trachea
Attachment of adult
Anorexia, epigastric pain
Gastro- worms and injury to
and gastro-intestinal
intestinal upper intestinal
hemorrhage
mucosa
Iron deficiency anemia,
Hematol
hypoproteinemia, edema, Intestinal blood loss
ogic
21.11.2022 cardiac failure 26
 Immunology
• Immune response is dominated by TH2, which
produce cytokine profile IL4,5,6,9,10, favoring
eosinophilia and Ab production
• The activated immune cells have the potential to
damage parasites via the secretion of toxic
granules and release of reactive oxygen
intermediates and nitric oxide(NO).
• This may, to some extent, be neutralized by the
secretion of glutathione-s-transferase and
superoxide dismutase
21.11.2022 27
 Immune evasion

• By secretion of an IgA protease that has the

potential to produce Fab fragments and
eosinophil de-granulation
• Blocking complement or phagocytic ingestion
mediated by IgG or IgM

21.11.2022 28
 Laboratory diagnosis
1. Finding eggs in faeces
2. PCR
3. Serological tests (IgG and IgE)

21.11.2022 29
 Laboratory diagnosis

1. Finding eggs in faeces

• Microscopic identification of eggs in the stool is
the most common method
• A.duodenale & N.americanus eggs
morphologically indistinguishable

21.11.2022 30
21.11.2022 31
 Diagnosis….
• Freshly passed faeces should be examined
• If more than 12 hours old ,a larva may be seen
inside the egg
• If more than 24 hours old ,the larva will hatched and
misslead with strongyloides larva
 hookworm : deep buccal cavity
 S. stercoralis : shorter buccal cavity

21.11.2022 32
21.11.2022 33
 Diagnosis…

2.PCR
 For diagnosis of A.duodenale infection
 Epidemiological studies and monitoring of
success of control programs

3. Serological tests (IgG and IgE)

21.11.2022 34
 Treatment
 Pyrantel pamoate, Mebendazole or
Thiabendazole
 if anemic : high protein diet supplemented
with ferrous sulphate, folic acid and vitamin
B12

Prevention and control

21.11.2022 35